Incomplete and Inaccurate Medical Record Documentation for Central Catheter and Insulin Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by multiple documentation lapses. For one resident with a peripherally inserted central catheter (PICC) line, the dressing was observed to be dated incorrectly, and the Treatment Administration Record (TAR) did not align with the physician's order for weekly dressing changes. Staff could not recall the reason for the discrepancy or explain the incorrect dating of the dressing. Additionally, two residents with orders for insulin therapy had incomplete or missing documentation in their Medication Administration Records (MAR). One resident's MAR had a blank entry for a scheduled insulin dose, and staff interviews revealed that while communication with the provider may have occurred, it was not documented in the medical record. Another resident with sliding scale insulin orders had multiple blood glucose readings above 400 mg/dl, but there was no documentation of physician notification or follow-up as required by the orders. The facility's policy requires accurate and timely documentation of all resident care and provider communications, which was not met in these cases.